P - 47741Building BUILDING Permit No.: �� '� f
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D �°,�� I
763-502-4977 FAX �� ��`��
EFFECT(VE I-1-2011
DATE — ��" �� %� YOUR E-MAIL ADDRESS
SITE ADDRESS 4a �/�,S' �i�i c� 6y� 5°�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NpME: c u/, n, ,
TENANT qDDRESS: �/7'a V �.
�QIl- CITY � F�lf STATE �%/�IP
PHONE: �� � 'J .� �— �' Q',�
CONTRACTOR NAME: LA�/I/�/YC� �',e���, e�s °'' �
SUBMIT A COPY OF STATE UCENSE # v20 �L6•SoZ c� � LEAD CERT NUMBER
YOUR STATE LICENSE
ANDCERTIFICATEOF ADDRESS: lol.�iG� fS.S`�`'� �a�- �1i� CITY /�Qtirs�.x3 STATE�✓�ZIP �'�
INSURANCE pHONE ' — '�/ --1� � � FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCT]ON S[ZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑�� �RAGE/SHED ❑ WINDOWS
� BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SW[MM1NG POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: "` %�_ c�_.2. d� J[.� �'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES Z� ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
� Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Cantrol
Park Fee
Sewer Main Charge
Total Due
$ `7 / �-�
$ `
$
$
$
$
$
$
$
$
� r a ,a
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks uavable to: Citv of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work whic r quires review and approval of pl `/
SIGNATURE OF APPLICANT C�e�l/ PRINT NAME ���l' L��Cti� DATE 6-/3- �/�
APPROVAL INSPECTOR SIGNATU